1447346499 NPI number — KEVIN JAMES MALTAIS CRNA

Table of content: KEVIN JAMES MALTAIS CRNA (NPI 1447346499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447346499 NPI number — KEVIN JAMES MALTAIS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALTAIS
Provider First Name:
KEVIN
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447346499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 E 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACONIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55387-4552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-442-9770
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
568 RUIN CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27536-2880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-436-1380
Provider Business Practice Location Address Fax Number:
252-436-1851
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  0024167055 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 181612 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8051607 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104867500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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